what do you mean by Acute Carpal Tunnel Syndrome? 7/14/2012 Acute Variants of Typically Chronic Conditions

Transcription

1 what do you mean by DMK Acute Causes of Chronic Conditions Acute Carpal Tunnel Syndrome? Acute Variants of Typically Chronic Conditions Acute Variants of Typically Chronic Conditions Kennedy-White Orthopaedic Center Sarasota, Florida David Klein, MD 1

2 Why this talk?? When the Diagnosis doesn t match an Acute Injury? Doctor, that s a chronic condition We re disallowing the claim, and closing the book on the file. NOT my goals Goals: Pathophysiology of common chronic orthopaedic conditions How these can happen in acute injuries No Strict Criteria Can t give Treatment Predictability 2

3 Conceptual talk not meat X and potatoes. Common ACUTE injuries Fractures Sprains and Strains Dislocations Lacerations Common ACUTE injuries Fractures Sprains and Strains Dislocations Lacerations 3

4 Common ACUTE injuries Fractures Sprains and Strains Dislocations Lacerations Common ACUTE injuries Fractures Sprains and Strains Dislocations Lacerations Common CHRONIC Injuries Tendonitis Arthritis Nerve Compression Contracture Common CHRONIC Injuries Common CHRONIC Injuries Tendonitis Arthritis Nerve Compression Contracture Tendonitis Arthritis Nerve Compression Contracture 4

5 Common CHRONIC Injuries Common CHRONIC Injuries Tendonitis Arthritis Nerve Compression Contracture Tendonitis Arthritis Nerve Compression Contracture That LAST List. That LAST List. quick aside 5

6 Obstetrics? quick aside Hypertension? Hypertension? Pre-eclampsia The END! 6

7 Thanks for Visiting! Drive Safely on Your Way Home! Inflammatory Post-Traumatic Idiopathic Types of Tendonitis Just kidding.back to orthopaedics Traumatic Tendonitis Dequervain s Trigger finger Rotator cuff syndrome Elbow epicondylitis Traumatic Tendonitis Dequervain s Trigger finger Rotator cuff syndrome Elbow epicondylitis 7

8 Traumatic Tendonitis Traumatic Tendonitis Dequervain s Trigger finger Rotator cuff syndrome Elbow epicondylitis Dequervain s Trigger finger Rotator cuff syndrome Elbow epicondylitis Goings on Collagen fibers tear don t heal More capillaries (angioblastic fibroplasia) Thicker tendon lining Fluid production (bursa or sheath) Goings on Collagen fibers tear don t heal More capillaries (angioblastic fibroplasia) Thicker tendon lining Fluid production (bursa or sheath) Goings on Collagen fibers tear don t heal More capillaries (angioblastic fibroplasia) Thicker tendon lining Fluid production (bursa or sheath) Goings on Collagen fibers tear don t heal More capillaries (angioblastic fibroplasia) Thicker tendon lining Fluid production (bursa or sheath) 8

9 Goings on Lateral epicondylitis Elbow hits doorframe Late-hit backhand? Rotator Cuff Tendonitis 9

10 An arm gets Yanked Twisted Pulled Does not improve rapidly with treatments Types of Arthritis Osteoarthritis Normal, or non-inflammatory Inflammatory Arthritis Post-Traumatic Arthritis MRI Tendinosis Changes When is Arthritis Acute?... [Post] Traumatic Arthritis 10

11 Arthritis Basics (all types) Cartilage destruction -- chemical & mechanical Ligament laxity Secondary stiffness/contracture Bony changes -- late General Types: General Types: Inflammatory Arthritis Inflammatory Arthritis Non-Inflammatory Arthritis Non-Inflammatory Arthritis Regular Arthritis Non-inflammatory Genetics Osteoarthritis Osteoarthritis 11

12 Inflammatory Body attacks itself (synovium) Genetic (but different) also Psoriatic, Reiter s (Reactive), Gout, CPPD, Lyme s, etc. Rheumatoid Arthritis Rheumatoid Arthritis More like Osteoarthritis -- Mechanical Post-Traumatic Arthritis Post-Traumatic Arthritis Ankle Traumatic Arthritis From persistent instability From significant injury From non-anatomic repair Can occur in 6-12 months 12

13 Wrist Traumatic Arthritis From intra-articular fractures From ligament instability injuries From intra-articular fractures From ligament instability injuries From intra-articular fractures From ligament instability injuries Wrist Traumatic Arthritis From intra-articular fractures From ligament instability injuries 13

14 Basal Joint Arthritis (thumb)? Usually inherited Frequently Asymptomatic until triggered. Nerve Model? Traumatic Nerve Compression Both ELECTRICAL and CHEMICAL Types of Nerve Compression Inflammatory Arthritic (usually only spinal roots) Post-Traumatic Idiopathic Nerve function? 14

15 Nerve damage? Nerve damage? Nerve Conduction Studies Remember, Nerve Fiber Linings (Myelin Sheath) Nerve Fiber Numbers (Axons) Loss of Lining Slow Conduction Loss of Fibers Less Signal Combined Myelin and Axon Injuries 15

16 Nerve Studies: EMG/NCV Nerve Studies: EMG/NCV EMG What everyone calls them EMG Electromyograph Accupuncture-like needles into muscle, and listen Healthy nerve and muscle quiet New nerve injury quiet At 3-5 weeks, muscle irritable EMGs frequently normal undercall problems NCS Nerve Conduction Studies NCS What most people mean when they say EMG (crazy colloquialisms!) NCS like testing a nerve with an electrical meter Looking for conduction speed/delay Looking for amplitude/size of conduction Nerve Studies: EMG/NCV Just +EMG: could mean radiculopathy Just +NCS: often means peripheral nerve compression, mild to moderate Just +NCS: could mean severe NCS, newer than 3-5 weeks Nerve Studies: EMG/NCV Accuracy? EMGs very examiner & temperature dependent EMG interpretation selection of muscles must help separate nerves from roots NCS more objective, still not flawless 16

17 H o w C a n N e r v e s G e t Compressed? Squashed from Without Squashed from Within Stretched or Tethered Wrist fracture and nerves? Blood in carpal canal Stretch from wrist hyperextension Crush against edge of fracture Funny bone not so funny Downstream Nerve Injuries same injuries Ulnar Nerve at the elbow 17

18 Downstream Nerve Injuries a common cause of post-injury nerve compression A dam downstream produces a lake upstream Double-Crush Syndrome Water Hose Example Double Crush Separate Compressions of the Same Nerve Fibers Usually neck and arm Symptoms Only When Above Threshold Maybe after injury Water hose and kids example Double Crush Threshold of Symptoms 18

19 Contractures Stiff Joints Shoulder Elbow PIP joint Knee Ankle Types of Contractures Stiff Joints Congenital Arthritic Post-Traumatic Neurologic Idiopathic Shoulder Elbow PIP joint Knee Ankle Stiff Joints Stiff Joints Shoulder Elbow PIP joint Knee Ankle Shoulder Elbow PIP joint Knee Ankle 19

20 Stiff Joints Shoulder Elbow PIP joint Knee Ankle Blood in joint inflammatory Muscle/Tendon balance lost stability Post-Traumatic Contracture Causes Stiffness? Symptom? Sign! I m talking about real, demonstrable, stiff-when-you re anesthetized loss of passive motion! not I feel stiff. <whimper> Like [Post] Traumatic Arthritis, this is [Post] Traumatic Contracture (rapidly after an injury) 20

21 Boutonnière Stiff Knee Elbow Contracture Special Contractures Heterotopic Ossification Following Burns Following Head Injuries Following Elbow Fractures 21

22 (Most Stiff Elbows do NOT involve H.O.) What to Expect After Injuries Sequela of Trauma What to Expect Down the Road Nerve Compressions Trigger Fingers and other Tendonitis Contractures Arthritis (only when joint itself injured) WHEN to Expect After Injuries Nerve Compressions ~ <6 months Trigger Fingers, Tendonitis ~ <6 months Contractures follow injury, 1-3 months Arthritis, post-traumatic 6 months to years 22

23 Summary: Examples of Acute and Chronic Injuries Basic Pathophysiology of Chronic Conditions Many Chronic Conditions HAVE Acute Variants Illustration by Example P o s t S c r i p t : DEMENTIA is a Chronic Condition When we all forget this talk by the time we are home, then that would be DELERIUM < which is an acute variation! > 23

24 24